Organization
PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Active
Other names
ACI Surgical Associates
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROBIN J. MADDOX (PROVIDER ENROLLMENT COORDINATOR)
(912) 350-9335
Entity
Organization
Contact information
Practice address
14 OKATIE CENTER BLVD. SOUTH, SUITE 101, OKATIE, SC 29909
(912) 350-2299
(912) 350-2298
Mailing address
PO BOX 102019, ATLANTA, GA 30368-2019
(912) 350-2299
(912) 350-2298
Taxonomy
Speciality
Code
Description
License number
State
207VX0201X
Gynecologic Oncology Physician
—
—
207Y00000X
Otolaryngology Physician
—
—
208600000X
Surgery Physician
—
—
2086S0102X
Surgical Critical Care Physician
—
—
2086X0206X
Surgical Oncology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DO4198
RR MEDICARE
SC
05
—
GP5024
—
SC
Enumeration date
09/04/2008
Last updated
05/03/2011
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